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Knee Replacement Patient Walks Same Day as Surgery

Debora Waxer’s history of knee injury and pain dates back to her college days when she played on the varsity basketball team at Massachusetts Institute of Technology (MIT).

“In one final game, a girl on the opposing team ran into me on the court, causing me to fall and damage the cartilage in my right knee as well as the anterior cruciate ligament (ACL),” she recalls. “I had to have surgery, and back in those days, they simply took out the entire cartilage.”

Now in her mid-50s, Ms. Waxer coped with pain in her knee over the years, trying everything she could to forestall additional surgery. In the past 10 years, however, the pain got progressively worse.

“I tried exercises and a couple of steroid injections,” she says. “I saw several doctors, who said I would probably need to have the knee replaced at some point. Then in January 2012, I fell again. I wasn’t even doing anything fun – I was just carrying something out to the car at night, and I missed the curb. This time I completely severed the ACL that had been damaged in my previous fall.”

At the time of her second knee injury, Ms. Waxer was living near Reno, Nevada. A doctor there recommended total knee replacement.

“I opted to try a knee brace, extending from my thigh to the calf, to see if I could do without knee replacement surgery for a while longer,” she explains. “Without the ACL, I had no stability in the knee, and it still hurt so much, but the brace did help line up the knee better.”

Ms. Waxer continued to postpone getting her knee replaced because of her demanding job commitments as an environmental and safety engineer for the U.S. Navy, working as a civilian. In November 2013, she returned to working in the Monterey, California area full-time. (She also works on a referral basis as a real estate broker.) Finally, in the spring of 2014, she decided to meet with orthopedic surgeon Alexander Sah, MD at the Washington Hospital Institute for Joint Restoration and Research (IJRR), where he and John Dearborn, MD serve as co-medical directors.

“I had heard many times over the years about Dr. Sah and Dr. Dearborn, and they came highly recommended by other doctors and a physical therapist,” she notes. “Dr. Sah agreed that the knee replacement needed to be done. Partial knee replacement or just surgery to repair the ACL weren’t considered viable options. I still had to wait for the surgery, though. I knew that I would need to take a fair amount of time off work to recover from total knee replacement. We were very short-staffed at work, and no one could fill in for me. We scheduled the surgery for December 2, 2014, so that I would be able to take time off around the holidays.”

One of the most experienced joint replacement surgeons in the Bay Area, Dr. Sah chose a newer, “personalized” knee implant for Ms. Waxer.

“Because she is a younger patient, I used an implant that offers more sizing options to better match individual patient anatomy,” he says. “It is also partly fixed by bone ingrowth, which can possibly increase the longevity of the knee replacement. I also used newer plastic liners that contain vitamin E as an antioxidant, to again possibly improve durability. In addition, I used aspirin instead of stronger blood thinners to prevent blood clots, while reducing the risk of postoperative bleeding and swelling in the knee.”

Dr. Sah had another innovative idea for improving Ms. Waxer’s surgery recovery and getting her back to work sooner – getting her to walk on the new knee within hours after surgery and possibly allowing her to go home the day after surgery. Prior to December 2014, knee replacement patients at the IJRR had not walked until the day after surgery, and most required a two- to three-day hospital stay.

“I’ve worked with many colleagues who are among the leaders in joint replacement surgery, going to meetings and conferences where we share our experiences and ideas, and I assimilate their best ideas into caring for my patients,” he explains. “Getting certain patients to walk the same day as surgery helps speed their recovery and provides equal – if not better – knee range of motion.”

Prior to starting the new protocol for having select knee replacement patients walk the same day as surgery, members of the IJRR physical therapy (PT) team had some concerns.

“We had always gotten knee replacement patients up the next day,” says PT Clinical Coordinator Alisa Curry, PT, DPT, GTC (physical therapist, doctorate of physical therapy, geriatric training certified). “Our standard practice was to ‘wean’ patients off their epidural anesthesia gradually. Dr. Sah’s new protocol called for taking patients off the epidural right after surgery and using an injectable, long-lasting local pain medication instead. So one concern was whether pain management would be as good with the new protocol. Another concern was whether post-operative swelling would be worse because of the increased early physical activity. The keys to great results after total knee replacement are pain management and control of swelling, and I didn’t want to sacrifice either of those.”

After the first three patients she had walking the same day as their knee replacement surgery, Curry’s concerns were put to rest.

“I realized this new protocol would be a game-changer,” she says. “I’m a member of the American Physical Therapy Association working on guidelines for total knee practice, and I knew that other facilities were getting patients up the same day. But those patients’ legs were still numb from femoral nerve blocks. I think Dr. Sah’s protocol for using the injectable pain medication after surgery is better because the patients can feel their legs. So they have better motor control, and we can safely mobilize them faster.”

The pre-operative education for all knee replacement patients at the IJRR was modified prior to Ms. Waxer’s surgery to let people know that they might be candidates for getting up to walk the same day as surgery.

“Now, with the patient education that we wrap around this change in protocol, I am definitely an advocate,” Curry admits. “Approximately 70 percent of Dr. Sah’s knee replacement patients are able to get up and walk the same day as surgery, and they can go home the next day. The patients are pleased to know they have the chance to continue their recovery at home – in their own bed, with their own food, and with no restrictions on people visiting – as opposed to staying in a facility. The patient education is an important component, letting them know what will take place and making them part of the recovery team with an important role to play in their own recovery process. They understand that while their knee is not healed, they are more functional and can participate better in their rehabilitation. They are managed very well from a pain standpoint to make this procedure very tolerable.”

Curry emphasizes that while every patient is not a candidate for next-day discharge, the patients’ ages don’t really matter as much as their condition and mobility prior to surgery. Other medical conditions might affect their recovery time, too. Range of motion at hospital discharge is a very important factor. Patients need to have at least between 90 and 110 degrees range of motion to be considered for going home the next day.

“Each patient is different, and we need to do a thorough evaluation of what is best for them,” she says. “Our team doesn’t just get people up walking and send them out the door. We have a long record of having patients leave with great range of motion – our average is 96 degrees at discharge, which is high compared to other facilities. We are creating a ‘better patient’ by having them be more functional and mobile at discharge, which helps in their recovery over the long run.”

In Ms. Waxer’s case, she was stable and steady on her feet, walking a short distance the evening of her surgery, according to Curry, who walked the patient the evening after her surgery.

“Ms. Waxer had 118-degree range of motion the day after surgery – well above where she needed to be in order to be safe and heal well at home,” says Curry. “She had climbed 10 stairs and walked 200 feet in the hallway easily with a walker. She walked out of the hospital that day with just a cane.”

From Ms. Waxer’s point of view, the experience was nothing short of “amazing.”

“I had my surgery around 9 a.m., and was back in my room by early afternoon,” she relates. “The pain control was really phenomenal. The physician’s assistant involved in my surgery and recovery, Abigail Goetz, and the nurses were all excellent. My husband Michael actually said, ‘Wow! Hospitals can be a positive experience, not torture!’"

“I was happy, but not too surprised, to be able to walk the same day,” she adds. “Dr. Sah and the staff had let me know ahead of time that walking the same day was a possibility. By the next day, my range of motion was equal to what is usually achieved after six to eight weeks. I also knew that the typical hospital stay for knee replacement was two days or longer, but I was really happy to go home after just one day. I felt ready to go.”

The IJRR arranged for Ms. Waxer to have a home health care nurse visit a couple of times a week for three weeks. She also received physical therapy at home, two to three times a week, through December.

“The transition of care from hospital to home was very well-coordinated,” she says. “Dr. Sah even called me at home once a day for several days to check on me. I never had a doctor do that before. I was really impressed. My husband and I are both MIT graduates, and we asked a lot of questions. Dr. Sah was very patient and thorough in answering.”

Ms. Waxer started outpatient physical therapy at a clinic and returned to work at her office in January. Three months later, she reports that her recovery is going well, with additional physical therapy to continue gaining more strength in her right leg and improving her posture.

“I was really limping before the surgery – my body had been out of alignment for more than 20 years – and I am so much better than I was,” she says. “Sometimes I think I shouldn’t have waited so long, because the outcome is so great! It was definitely a better option to wait and to travel from the coast to Fremont so I could have Dr. Sah for my surgeon. I was very impressed with the educational efforts and the amazing care from all members of the team. I also thought Dr. Sah’s protocol for walking the day of surgery was excellent – it worked really well for me. I am absolutely thrilled with the results, and I highly recommend Dr. Sah and the whole team at Washington Hospital.”

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